Provider Demographics
NPI:1952475949
Name:DR BYRON K. BRIDGES DDS PA
Entity Type:Organization
Organization Name:DR BYRON K. BRIDGES DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYON
Authorized Official - Middle Name:K
Authorized Official - Last Name:BRIDGES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS PA
Authorized Official - Phone:864-836-8416
Mailing Address - Street 1:P.O. BOX 491
Mailing Address - Street 2:3037 GERR HWY
Mailing Address - City:MARIETTA
Mailing Address - State:SC
Mailing Address - Zip Code:29661-0491
Mailing Address - Country:US
Mailing Address - Phone:864-836-8416
Mailing Address - Fax:864-836-0780
Practice Address - Street 1:3037 GEER HWY
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:SC
Practice Address - Zip Code:29661
Practice Address - Country:US
Practice Address - Phone:864-836-8416
Practice Address - Fax:864-836-0780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ11719Medicaid
SC1952475949Medicaid
SCZA11719Medicaid